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Safe sex is defined as "Sexual activity engaged in by people who have taken precautions to protect themselves against sexually transmitted diseases such as AIDS." [1]This is also referred to as safer sex, or protected sex, while unsafe sex or unprotected sex is sexual activity engaged in by people who have not taken precautions to protect themselves against sexually transmitted infections. Some sources suggest the use of safer sex is preferable to safe sex, as this reflects that risk is reduced, not avoided.[2]

Safe sex practices became more prominent in the late 1980s as a result of the AIDS epidemic. Promoting safe sex is now a principal aim of sex education. From the viewpoint of society, safe sex can be regarded as a harm reduction strategy aimed at reducing risks.

The risk reduction of safe sex is not absolute; for example the reduced risk to the receptive partner of acquiring HIV from HIV seropositive partners not wearing condoms to compared to when they wear them is estimated to be about a four- to fivefold.[3]

Although some safe sex practices can be used as contraception, most forms of contraception don't protect against all or any STIs; likewise, some safe sex practices, like partner selection and low risk sex behavior, aren't effective forms of contraception.

Terminology

Recently, and mainly within Canada and the United States, the use of the term safer sex rather than safe sex has gained greater use by health workers, with the realization the grounds that risk of transmission of sexually transmitted infections in various sexual activities is a continuum rather than a simple dichotomy between risky and safe. However, in most other countries, including the United Kingdom and Australia, the term safe sex is still mostly used by sex educators.

Focus on condoms and HIV control

Much attention has focused on controlling HIV, the virus that causes AIDS, through the use of barrier protection for the penis, especially condoms. However, the HIV is a delicate virus, so protections focused on HIV may not protect against other STIs, which can also be transmitted through other areas of the body where the pathogen (virus or bacteria) has higher prevalence and resistance. Thus some sex educators recommend the use of barrier protection for any sexual contact with anal or vaginal cavities, or oral stimulation of those cavities or the penis.

Safe sex precautions

Avoiding physical contact

Known as autoeroticism, solitary sexual activity is relatively safe. Masturbation, the simple act of stimulating one's own genitalia, is safe so long as contact is not made with other people's discharged bodily fluids. Some activities, such as "phone sex" and "cybersex", that allow for partners to engage in sexual activity without being in the same room, eliminating the risks involved with exchanging bodily fluids.[4]

Non-penetrative sex

A range of sex acts, sometimes called "outercourse", can be enjoyed with significantly reduced risks of infection and pregnancy. U.S. President Bill Clinton's surgeon general, Dr. Joycelyn Elders, tried to encourage the use of these practices among young people, but her position encountered opposition from a number of outlets, including the White House itself, and resulted in her being fired by President Clinton in December 1994.[5][6][7]

Barrier protection

Various protective devices are used to avoid contact with blood, vaginal fluid, semen or other contaminant agents (like skin, hair and shared objects) during sexual activity. Practice of sexual activity using this devices is called protected sex.

Condoms cover the penis during sexual activity. They are most frequently made of latex, but can also be made out of polyurethane. Polyurethane is thought to be a safe material for use in condoms, since it is nonporous and viruses cannot pass through it. However, there is less research on its effectiveness than there is on latex.

Female condoms are inserted into the vagina prior to intercourse. They may also be used for anal sex, although they are less effective.[citation needed]

A dental dam (originally used in dentistry) is a sheet of latex used for protection when engaging in oral sex. It is typically used as a barrier between the mouth and the vulva during cunnilingus or between the mouth and the anus during anilingus.

Medical gloves made out of latex, vinyl, nitrile, or polyurethane may be used as an makeshift dental dam during oral sex, or to protect the hands during sexual stimulation, like in masturbation. Hands may have invisible cuts on them that may admit pathogens or, more usually, serve as vehicle for contamination of other body part or partner.

Another way to protect against pathogen transmission is the use of protected or properly cleaned dildos or other sex toys. If a sex toy is to be used in more than one orifice or partner, a condom can be used over it and changed when the toy is moved.

When latex barriers are used, oil-based lubrication can break down the structure of the latex and remove the protection it provides.

Condoms (male or female) are used to protect against STIs, and used with other forms of contraception to improve contraceptive effectiveness. For example, simultaneously using both the male condom and spermicide (applied separately, not pre-lubricated) is believed to reduce perfect-use pregnancy rates to those seen among implant users.[8] However, if two condoms are used simultaneously (male condom on top of male condom, or male condom inside female condom), this increases the chance of condom failure.[9][10]

Proper use of barriers, such as condoms, depends on the cleanness of surfaces of the barrier, handling can pass contamination to and from surfaces the barrier unless care is taken.

Other precautions

Acknowledging that it is usually impossible to have entirely risk-free sex with another person, proponents of safe sex recommend that some of the following methods be used to minimize the risks of STI transmission and unwanted pregnancy.

Male Circumcision and HIV : Some recent research, and advice from the World Health Organisation (WHO), has suggested that circumcision of males can be useful in preventing the spread of HIV infection in some countries. Male circumcision is acknowledged by the WHO as a preventative measure against HIV transmission from women to men. African studies have found that circumcision can reduce the rate of transmission of HIV to men by up to 60%.[11] Some advocacy groups dispute these findings.[12][13] However, at least in sub-Saharan Africa, condom use is estimated to be much more cost effective.[14]

Periodic STI testing has been used to reduce STIs in Cuba and among pornographic film actors. Cuba implemented a program of mandatory testing and quarantine early in the AIDS epidemic.[15] In the US pornographic film industry in the US, many production companies will not hire actors without tests for Chlamydia, HIV and Gonorrhea that are no more than 30 days old-and tests for other STIs no more than 6 months old. AIM Medical foundation claims that program of testing has reduced the incidence of sexually transmitted infection to 20% of that of the general population.[16] Douching with soap and water has not been studied and it is thought that by disrupting the vaginal flora it might increase risk of infection.[17]

Monogamy or polyfidelity, practiced faithfully, is very safe (as far as STIs are concerned) when all partners are non-infected. However, many monogamous people have been infected with sexually transmitted diseases by partners who are sexually unfaithful, have used injection drugs, or were infected by previous sexual partners; the same risks apply to polyfidelitous people, who face higher risks depending on how many people are in the polyfidelitous group.

For those who are not monogamous, reducing the number of one's sexual partners, particularly anonymous sexual partners, may also reduce one's potential exposure to STIs. Similarly, one may restrict one's sexual contact to a community of trusted individuals - this is the approach taken by some pornographic actors and other non-monogamous people.

When selecting a sexual parter, some characteristics can increase the risks for contracting sexually transmitted diseases.[18] These include:- an age discordance of more than five years;[18] having an STI in the past year;[18] problems with alcohol;[18] having had sex with other people in the past year[18]

Communication with one's sexual partner(s) makes for greater safety. Before initiating sexual activities, partners may discuss what activities they will and will not engage in, and what precautions they will take. This can reduce the chance of risky decisions being made "in the heat of passion".

Refraining from the use of recreational drugs, including alcohol, before and during sexual activity can protect against associated risks such as lowered inhibitions, decreased immune response, impaired judgment, and loss of consciousness.

If a person is sexually active with a number of partners, regular sexual health check-ups from a doctor are a precaution taken, and on noticing unusual symptoms seeking prompt medical advice; HIV and other infectious agents can be either asymptomatic or involve nonspecific symptoms which on their own can be misdiagnosed.[19][20]

Limitations

While the use of condoms can reduce transmission of HIV and other infectious agents, it does not do so completely. One study has suggested condoms might reduce HIV transmission by 85% to 95%; effectiveness beyond 95% was deemed unlikely because of slippage, breakage, and incorrect use.[21] It also said, "In practice, inconsistent use may reduce the overall effectiveness of condoms to as low as 60–70%".[21]p. 40.

During each act of anal intercourse, the risk of the receptive partner acquiring HIV from HIV seropositive partners not using condoms is about 1 in 120. Among people using condoms, the receptive partner's risk declines to 1 in 550, a four- to fivefold reduction.[3] Where the partner's HIV status is unknown, "Estimated per-contact risk of protected receptive anal intercourse with HIV-positive and unknown serostatus partners, including episodes in which condoms failed, was two thirds the risk of unprotected receptive anal intercourse with the comparable set of partners."[3]p. 310.

Using two or more forms of birth control concurrently

Risk of accidental pregnancy

BEST case scenario assuming PERFECT use

Per Year (assuming 100 sex acts)

Per Act

No protection

8 in 10 (1 in 1.25)

1 in 125

Condoms

1 in 50

1 in 5,000

Birth Control

1 in 333

1 in 33,300

Condoms & Birth Control

1 in 1,665,000*

1 in 166,500,000

50*333*100

What the above figures mean is that in one year, 80 out of 100 couples using no protection will get pregnant. 2 out of 100 couples using just condoms will get pregnant, .3 out of 100 couples using just hormonal birth control will get pregnant, and .00006 out of 100 couples using both condoms and birth control will get pregnant.

Using 2 or more forms of birth control dramatically reduces the risk of unplanned pregnancy. Use at least condoms and the pull-out method together unless sure the female is on hormonal. If sure, use hormonal and condoms until sure there are no diseases. Then hormonal and pull-out is an option (or hormonal and diaphragm, or pull-out and diaphragm). Never use the pull-out method by itself. The typical success rate is 1 in 3.7 per year. Always try to use at least two forms of birth control. In 10 years, the risk with just hormonal rises from 1 in 333 couples to 1 in 33.3 couples. This is assuming perfect use of the contraceptive. The typical use numbers are even riskier:

Risk of accidental pregnancy

WORST case scenario assuming TYPICAL use

Per Year (assuming 80 sex acts)

Per Act

No protection

8 in 10 (1 in 1.25)

1 in 125

Condoms

1 in 6.6

1 in 533

Birth Control

1 in 12.5

1 in 1,000

Condoms & Birth Control

1 in 6,666*

1 in 533,333

6.66*12*80

In typical use (including forgetting to take the pill or not understanding instructions or things like that) 8 in 100 (1 in 12.5) couples using just hormonal birth control will get pregnant each year. The true risk must be somewhere in between Perfect, and Typical use.

If you care to ejaculate in the vagina for sexual bonding, only do so infrequently. In 10 years of typical use of only hormonal, the risk rises from 8 in 100 (1 in 12.5) to 80 in 100 (1 in 1.25) couples. See [22] for reference on above tables.

The spermicideNonoxynol-9 has been claimed to reduce the likelihood of STI transmission. However a recent study by the World Health Organization[23] has shown that Nonoxynol-9 is an irritant and can produce tiny tears in mucous membranes, which may increase the risk of transmission by offering pathogens more easy points of entry into the system. Condoms with Nonoxynol-9 lubricant do not have enough spermicide to increase contraceptive effectiveness and are not to be promoted.[citation needed]

Coitus interruptus (or "pulling out"), in which the penis is removed from the vagina, anus, or mouth before ejaculation, is not safe sex and can result in STI transmission. This is because of the formation of pre-ejaculate, a fluid that oozes from the urethra before actual ejaculation, may contain pathogens such as HIV.[24][25] Additionally, the microbes responsible for some diseases, including genital warts and syphilis, can be transmitted through skin-to-skin contact, even if the partners never engage in oral, vaginal, or anal sexual intercourse.

Abstinence

Sexual abstinence is sometimes promoted as a way to avoid the risks associated with sexual contact, though STIs may also be transmitted through non-sexual means. HIV may be transmitted through contaminated needles used in tattooing, body piercing, or injections. Medical or dental procedures using contaminated instruments can also spread HIV, while some health-care workers have acquired HIV through occupational exposure to accidental injuries with needles.[26]

It is often recommended that those using abstinence have condoms available as a backup for protection against STIs and pregnancy.[27]

Some groups, notably some evangelical Christians and the Roman Catholic Church oppose sex outside marriage, and object to safe-sex education programs because they believe that providing such education promotes promiscuity. Virginity pledges and sexual abstinence education programs are often promoted in lieu of contraceptives and safe-sex education programs. This may entail exposing some teenagers to increased risk of sexually transmitted infections, because about 60 percent of teenagers who pledge virginity until marriage do engage in pre-marital sex and are then one-third less likely to use contraceptives than their peers who have received more conventional sex education.[28]

Anal sex

Unprotected anal penetration is a high risk activity regardless of sexual orientation. Research suggests that although gay men are more likely to engage in anal sex, heterosexual couples are more likely not to use condoms when doing so.[29]

Anal sex is a higher risk activity than vaginal intercourse, because the thin tissues of the anus and rectum can be easily damaged; this includes by the use of anal toys. Slight injuries can allow the passage of bacteria and viruses, including HIV. Anal stimulation with a sex toy requires similar safety measures to anal penetration with a penis, in this case using a condom on the sex toy in a similar way. Oil-based lubricants damage latex, and water-based lubricants are available instead, and non-latex condoms are available for people who are allergic to latex (e.g., polyurethane condoms that are compatible with both oil-based and water-based lubricants).[citation needed]

Sex toys

Putting a condom on a sex toy provides better sexual hygiene and prevents transmission of infections if the sex toy is shared, provided the condom is replaced when used by a different partner. Some sex toys are made of porous materials, and pores retain viruses and bacteria, which makes it necessary to clean sex toys (plugs, anal vibrators) thoroughly, preferably with use of cleaners specifically for sex toys. Glass sex toys are non-porous and more easily sterilized between uses.[citation needed]